Prostate cancer is the most common cancer of men above 50 in the United States causing abdominal pain. It is for men what breast cancer is for women and this is true even on a histological level, as both cancers are mostly glandular cancers (=adenocarcinomas) and both are responding to hormones, breast cancer to estrogen and prostate cancer to testosterone.
About 200,000 new cases of prostate cancer are diagnosed in the U.S. every year. The cancer grows slowly for a long period of time inside the very tough prostatic capsule. Often it switches to the other prostatic lobe (there are two lobes of the prostate gland). Next it breaks through the capsule and invades the adjacent structures such as the seminal vesicles, the urethra, bladder, pelvic lymph glands, the pelvic bone and via the blood stream enters bones such as vertebral bodies or ribs.
Prostate Cancer Symptoms
In the beginning of prostate cancer there are no symptoms. This is why an annual prostate examination and annual PSA blood test should be done once a year on every man 50 years or older.
In case of early prostate cancer the physician would pick up a hard lump in the prostate on rectal examination and often the PSA would be positive (greater than 5). A late sign of prostate cancer is when there is a bladder outlet obstruction with urgency, frequent urination or blood in the urine. At this point the prostate capsule is likely ruptured with local invasion, which would be a stage C out of 4 stages (stage A to D). When the cancer invades into the pelvic bone there would be pain in that area. With vertebral bone metastases spontaneous compression fractures can develop, with other bone metastases pathological fractures can spontaneously occur.
Prostate Cancer Tests
In the beginning there might be no symptoms. This is where the question of PSA screening has been discussed among physicians for a long period.
Some consensus seems to be developing. As the PSA test is very sensitive, but not specific (as mentioned before, BPH also often shows a positive PSA test), efforts are made to make the test more specific by measuring the proportion of free versus protein bound PSA. The physician also will likely order a transrectal ultrasound (=TRUS), which would show hypoechoic lesions where the examining finger feels hard lumps. Another blood test, the serum acid phosphatase test, is useful as it correlates well with lymph gland invasion, but it is not specific for prostate cancer alone.
Other conditions such as multiple myeloma or hemolytic anemia would, for instance, also give a positive test. However, a negative serum acid phosphatase test is reassuring that the prostate cancer has not yet metastasized. The definitive test for prostate cancer after all the other tests is a TRUS (=transrectal ultrasound) guided transrectal needle biopsy. This can be done in a clinic without an anesthetic and usually 6 separate locations throughout the prostate are sampled to increase the accuracy. The pathologist will then analyze these biopsy samples. This method is very accurate and very specific and must be done to confirm or rule out prostate cancer.
As in all cancers a tissue diagnosis is the only way how to diagnose cancer of the prostate, this is a “must”.
Prostate Cancer Treatment
In stage A or B cancer, where the prostate cancer has not extended beyond the prostate capsule, a radical selective prostatectomy can be performed, which will safe this man’s life.
Let me explain: In the past many urologists were of the opinion that there would be a “clinically irrelevant” prostate cancer entity, as it often takes very long for prostate cancer to metastasize. This is quite contrary to breast cancer where the cancer metastasizes early. The difference is that in breast cancer there is no capsule that confines the cancer, but in prostate cancer there is a very tough prostate capsule, which confines the cancer cells until late stage B prostate cancer. One of the big reasons why a man may not want to go for surgery is the fear that he may lose his ability to have sex. Similar to the TURP procedure, where loss of impotence is an issue (see chapter on “enlarged prostate”) this concern is very much in the mind of the man who is advised to have a radical selective prostatectomy.
In the past with a radical prostatectomy the nerves supplying impulses to the penis for erection were severed. However, now the urologist can explain that with the help of new technology using an operating microscope, in most cases the selective radical prostatectomy can preserve the nerves to the penis and therefore preserve potency after the surgical procedure is done. However, the urologist can only do what is technically possible and unfortunately there will be some cases where cancer tissue that has to be removed has encased the nerve supply. In such a case in the interest of the survival of the man’s life, the nerves might have to be severed as the cancer is removed.
Overall the statistics show that about 85% of stage A and B prostate cancer patients can have a successful selective radical prostatectomy and only 15% lose their potency. For stage C cancer local radiotherapy treatments or radioactive seed implants will likely slow cancer growth for a period of time, but survival rates are much worse than for patients after a selective radical prostatectomy. Occasionally the urologist might combine the two. In late stage C and D prostate cancer patients hormone therapy aimed at removing testosterone from the system can often buy significant survival time.
The most effective method is a bilateral orchiectomy (=removal of both testicles). A medical castration can also be achieved with luteinizing hormone-releasing hormone analogues. The urologist will explain, which therapy would be the best fit for a particular patient. In late stage D patients emphasis is placed on pain relief with local radiotherapy to bone metastases and possibly some chemotherapy to slow down cancer growth.
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